Atsb transport safety investigation report
Boeing 747: December 2001
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- Airbus A330: June 2002
- Boeing 747: March 2003
- Airbus A321: September 2003
- Boeing 747: October 2003
- Airbus A340: July 2004
- History of the flight 10
- Boeing 747: October 2004
- Airbus A340: August 2005
- Embraer 190: July 2006
- Boeing 747: December 2006
- Airbus A340: March 2007
- McDonnell Douglas MD83: September 2007
- Airbus A330: October 2008
- Boeing 767: December 2008
Boeing 747: December 2001
History of the flightOn 28 December 2001, the crew of a Boeing Company 747-128 aircraft, registered N3203Y, made a scheduled fuel stop at Anchorage, Alaska in preparation for the final leg of the flight to Travis Air Force Base, US. During the stop, about 100,000 lbs (45,360 kg) of fuel was uploaded. The crew failed to take into account the additional fuel uploaded, and inadvertently used the performance cards from the previous landing for the takeoff. During the takeoff, the aircraft sustained a tailstrike resulting in substantial damage. Contributing factorsThe subsequent investigation determined that the probable cause of the accident was the crew’s inadequate pre-flight planning and the fact they had not calculated the weight and balance for the takeoff. Airbus A330: June 2002
History of the flightOn 14 June 2002, an Airbus 330-343 aircraft, registered C-GHLM, was operating on a scheduled passenger service from Frankfurt, Germany to Montreal, Canada with 13 crew and 253 passengers on board. While preparing the aircraft for the flight, the crew received the initial load figures from the ACARS and entered the TOW (222,700 kg) and V speeds into the MCDU. Shortly after, the crew received the final load figures with a revised TOW of 221,200 kg. During pushback or taxi, the pilot not flying inserted the final load figures and V speeds into the MCDU. When doing so, a V1 speed of 126 kts was entered instead of 156 kts. The crew did not detect the error. During the takeoff, aircraft rotation was initiated at 133 kts. Due to over rotation the aircraft sustained a tailstrike. Contributing factorsThe following factors were identified throughout the subsequent investigation: An erroneous V1 speed was entered into the MDCU. The error was not detected by the crew. The V speeds were re-inserted into the MCDU, although this was not required as the speeds initially provided by the ACARS were valid for any aircraft TOW between 219,100 and 223,600 kg.
History of the flightOn 11 March 2003, a Boeing Company 747-300 aircraft, registered ZS-SAJ, was scheduled to depart Johannesburg, South Africa on a scheduled passenger service to Sao Paulo, Brazil. During flight preparations, the crew were distracted with the auxiliary power unit (APU), which failed to provide sufficient airflow into the cockpit and cabin area. They were also advised by ATC of an expected 45-minute delay. When given a start clearance from ATC, the delay was reduced to 30 minutes. The flight engineer received the aircraft loadsheet and inadvertently entered the ZFW into the handheld performance computer instead of the TOW. The resultant V speeds were transferred onto the take-off data card. The captain checked the V speeds as the first officer, who normally did this, was busy. Both pilots set the speed bugs on their respective airspeed indicators. During the take-off run, the captain sensed that the aircraft was nose heavy. In response, the rotation was delayed by 15 kts. After becoming airborne, the captain felt that the aircraft was sluggish and he requested more thrust. At the same time, the flight engineer stated that the aircraft was sinking. The captain kept the aircraft’s nose down to gain more speed and the aircraft climbed away. The crew were notified by ATC that the aircraft had sustained a tailstrike.
Contributing factorsThe following factors were identified throughout the subsequent investigation: The flight engineer unintentionally entered the ZFW instead of the TOW into the handheld performance computer. The crew were distracted by problems associated with the APU, and the 45 minute delay by ATC suddenly reduced to 30 minutes.
Boeing 747: March 2003
History of the flightOn 12 March 2003, a Boeing Company 747-412 aircraft, registered 9V-SMT, was being prepared for a scheduled passenger service from Auckland, New Zealand to Singapore. Onboard the aircraft were the captain, two first officers, 17 cabin crew and 369 passengers. About 1 hour prior to the scheduled departure, the crew commenced preparing for the flight. The aircraft had been refuelled with a predetermined amount of 100,000 kg; however, during flight planning, the crew determined that extra fuel was required. An additional 7,700 kg was needed, but only 4,500 kg was uploaded into the centre fuel tank by the refueler. The crew boarded the aircraft and about 15 minutes prior to departing, they realised that the centre tank had not been refuelled with the required amount. They subsequently requested the additional fuel and a revised loadsheet. The final loadsheet was delivered to the crew at about the same time the aircraft was scheduled to depart. The loadsheet showed the ZFW as 230,940 kg and the TOW as 347,340 kg. The flight was delayed by about 13 minutes. The captain referred to the loadsheet and called out certain information such as the ZFW, TOW and stabiliser trim setting for the first officer to write on the take-off data card. The first officer then referred to the aircraft’s fuel quantity indication and wrote the take-off fuel weight under the ZFW on the card. When doing so, the first officer wrote 247,400 kg in the TOW box, 231,000 kg in the ZFW box and 116,000 kg of take-off fuel on the bottom of the card. The first officer normally added these figures together to verify the TOW. He also added 2,000 kg to the TOW for an atmospheric pressure correction adjustment. The adjusted TOW was 249,900 kg, which the first officer wrote on the card.
Source: Transport Accident Investigation Commission, 2003 Using a TOW of 250,000 kg, rounded up, the first officer referenced the airport analysis chart and obtained the V speeds. In accordance with the aircraft manufacturer’s before-start operating procedures, the first officer computed the take-off data and prepared the take-off data card, and then passed the card onto the captain to verify the data. The captain did not verify the TOW and subsequently used the incorrect TOW to verify the V speeds. The captain checked the onboard fuel value on the flight management computer (FMC) with the required fuel weight. As the weights were similar, he entered the ZFW from the loadsheet into the FMC. The FMC automatically added the ZFW with a computed onboard fuel weight to display a gross weight. The captain verified that the FMC calculated gross weight corresponded with the TOW from the loadsheet. The captain manually entered the V speeds calculated by the first officer into the FMC, replacing the V speeds values automatically calculated by the FMC. The captain placed the take-off data card and airport analysis chart on the centre pedestal. Normally, the second first officer (third pilot) would cross check the card data and computations, however, he stowed the airport analysis chart without verifying the data. At this time, the third pilot was explaining the departure delay to the operation’s station manager. During the takeoff, the first officer called ‘V1’ when the aircraft’s speed reached 123 kts and called ‘rotate’ when it reached 130 kts. At 132 kts, the captain initiated the rotation for lift-off and the tail struck the runway, scraping for about 490 metres before becoming airborne. Contributing factorsThe following factors were identified throughout the subsequent investigation: The first officer incorrectly wrote a TOW of 247,400 kg on the take-off data card instead of 347,400 kg. He then referred to the airport analysis chart and used the incorrect TOW to determine the V speeds.
The captain did not verify the correct TOW and used the incorrect weight to confirm the V speeds. The delay due to refuelling may have put pressure on the crew to hurry their preparations. The captain was experienced, but had only recently converted to the Boeing 747-400; the first officer was considered experienced on type, but relatively inexperienced overall. Prior to flying the Boeing 747-400, the captain had been flying the Airbus A340 aircraft, where a typical VR speed was 138 kts. There were no specific duties assigned to the third pilot. The use of this pilot was at the captain’s discretion. There was no policy to compare the take-off data card V speeds with those automatically computed by the FMC. However, it was common practice for the pilots to reconcile the figures between the two sources. The FMC did not challenge V speed discrepancies between what was automatically computed with what was manually entered.
History of the flightOn 4 September 2003, the crew of an Airbus A321-232, registered OY-KBK, were preparing the aircraft for a scheduled flight from Oslo, Norway to Copenhagen, Denmark. During the pre-flight preparations, the crew were unable to calculate the take-off performance data using the ACARS as the datalink was not operating. The crew contacted the airline’s duty flight operations officer at Oslo requesting assistance. The duty officer was unable to help the crew as the portable computer used to complete the task was not working. The captain then requested that the dispatch office in Copenhagen be contacted and make the necessary calculations. The captain relayed the aircraft’s TOW (76,400 kg), runway in use and current weather conditions over the radio for the flight operations officer in Oslo to pass on to Copenhagen. The flight operations officer noted down the values provided by the captain, but reportedly only passed on the runway in use, wind and QNH9 to Copenhagen as they already had access to the former information, with the exception of the runway in use. The flight operations officer then received a fax from Copenhagen with the completed calculations. The person at Copenhagen who received this information stated that a TOW of 60,000 kg was also provided. He then reportedly telephoned Oslo to confirm the TOW as he believed it to be too low. The flight operations officer reportedly confirmed that 60,000 kg was correct. The take-off data calculations were made and then faxed to Oslo. The flight operations officer contacted the crew via radio and relayed the values from the fax. Both crew members took notes while listening to the call. The captain then read back all the values and received confirmation that they were correct. The crew queried the low V1 value, however, they were satisfied that it was correct as the value read back was confirmed. The first officer entered the V speeds and FLEX temperature into the aircraft’s flight management guidance and envelope computer (FMGC). During the takeoff, the first officer noticed that the aircraft’s response was sluggish. Once airborne, the crew observed that the V2 speed bug on the primary flight display was lower than normal. The aircraft’s speed was accelerated to 250 kts and the climb out continued. Contributing factorsThe following factors were identified throughout the subsequent investigation: The take-off calculations were based on a TOW of 60,000 kg instead of 76,400 kg, resulting in low V speeds.
There was no procedure for manually calculating take-off data when the datalink was not operational. The flight operations officer had received training in the use of the laptop and current take-off data computer program; however, these skills were rarely used. An investigation conducted by the airline determined the flight operations officer and other employees did not have sufficient knowledge and proficiency with respect to take-off calculations for the Airbus aircraft. The airline’s investigation also determined that it was not clear as to what services were provided by the various support departments. • The FMGC did not suggest default V speed values based on the TOW entered into the system. Boeing 747: October 2003
History of the flightOn 22 October 2003, a Boeing Company 747-200F aircraft, registered JA8191, was scheduled to operate a cargo flight from New Tokyo International Airport, Japan to Anchorage, US. Onboard the aircraft were the captain, a foreign pilot training for first officer, the flight engineer, and the first officer. On arrival at the aircraft, the flight engineer noticed that loading of the aircraft was behind schedule. The load planner provided the weight and balance manifest to the crew and the flight engineer prepared the take-off data card. The flight engineer wrote down the ZFW (552,700 lbs – 250,705 kg) and the estimated landing weight (579,800 lbs – 262,997 kg) in the margin on the flight engineer record. The aircraft’s TOW was 745,000 lbs (337,932 kg). When obtaining the V speeds from the relevant take-off charts, the flight engineer used a TOW of 550,000 lbs (249,480 kg) (Figure 10). The flight engineer typically verified the data by doing a reverse lookup, reading the TOW from the speeds, but as he didn’t want to delay the flight any further, the check was not done. Figure 10: Take-off performance chart 
The flight engineer handed the take-off data card to the captain, and the airspeed bugs on the airspeed indicator were set. During the taxi, the crew completed the taxi and take-off checklist, which involved setting and cross-checking the airspeed bugs against the take-off data card. During the takeoff, the trainee pilot called ‘VR’ and the captain applied aft pressure on the control column at the standard rotation rate. The captain felt that liftoff took longer than normal. When passing 3,000 ft on climb, the stall warning stick shaker activated. The captain responded by reducing pitch and asking the flight engineer to re-check the take-off performance data. It was noted that the V2 value used was about 28 kts less than what was required. The aircraft was returned to the airport, where the engineers found abrasions on the lower part of the aft fuselage, indicating a tailstrike occurred during the takeoff.
Contributing factorsThe following factors were identified throughout the subsequent investigation: The flight engineer had determined the V speeds based on the ZFW of 249,480 kg instead of a TOW of 337,932 kg. The flight engineer had written the ZFW value on the flight engineer record and this value remained in his mind.
The flight engineer did not verify the take-off data as the flight was running behind schedule. The captain, training pilot, and first officer did not doubt or cross-check the V speed values presented on the take-off data card. The trainee pilot stated that aircraft weight always used in simulator training was 530,000 lbs (240,408 kg). The trainee had previously used kilograms as a unit of measurement in his home country instead of pounds, and did not immediately detect the mistake in the numbers. From the operations manual it could be determined that the flight engineer was responsible for preparing the take-off data card, but there was mention of who was responsible for confirming the data. Source: Aircraft and Railway Accidents Investigation Commission, 2004 Airbus A340: July 2004
History of the flight10On 14 July 2004, an Airbus A340-300 aircraft, registered F-GLZR, was being prepared for a passenger service, departing from Charles de Gaulle Airport, France. In preparation for the flight, the crew received an expected TOW of 268,600 kg, which was close to the aircraft’s maximum take-off weight (MTOW) of 271,000 kg. The TOW, rounded up to 270,000 kg, was used to submit a take-off data calculation request via the ACARS. The resultant take-off performance parameters were verified by the crew. Shortly after, the crew were advised that the TOW was 5,200 kg less than that previously provided, resulting in a TOW of 264,800 kg. As the change in weight was greater than 5,000 kg, the crew were required to submit a new ACARS request. When entering the revised TOW into the ACARS via the FMGS interface, a weight of 165,000 kg was inadvertently entered. This weight was close to the ZFW of 164,480 kg. The resultant V speeds and FLEX temperature were then entered into the FMGS. The captain confirmed the parameters; however, he did not detect the error as he read the MTOW from the ACARS printout instead of the TOW. During the takeoff, the pilot flying reported the aircraft feeling heavy and noticed that the V2 speed was slower than the VLS speed (the lowest selectable speed, which provides an appropriate margin above the stall speed); take-off/go-around thrust was not applied. The aircraft sustained a tailstrike, with the fuselage remaining in contact with the runway for a distance of about 100 metres.
Contributing factorsThe following factors were identified throughout the subsequent investigation: A weight similar to the ZFW was inadvertently entered into the ACARS instead of the actual TOW, resulting in low V speeds.
The FMGS would accept unrealistic low V speeds without challenge. The FMGS did not compare the V2 and VLS speeds, despite the fact that both values were known before takeoff. The presentation of the parameter values on the ACARS printout may have led to some confusion in reading between the TOW and ZFW. The take-off briefing procedures did not require a comparison between the TOW and speed characteristics. Boeing 747: October 2004
History of the flightOn 13 October 2004, a Boeing 747-244SF aircraft, registered 9G-MKJ, was planned to operate a multi-stage non-scheduled international cargo flight departing from Luxembourg. The flight plan was as follows:
The crew complement for the flight consisted of two captains, one first officer, two flight engineers, a loadmaster and a ground engineer. Prior to departing the hotel in Luxembourg, the crew were advised that the aircraft would be delayed due to its late arrival at Luxembourg and late preparation of the cargo. During loading, the loadmaster noted that some of the pallets were contaminated. The loadmaster and another company employee commenced cleaning the pallets, but so not to delay the flight any further, this was continued enroute. The aircraft departed Luxembourg at 1556 and arrived at Bradley at 2322, where the cargo was offloaded. The loading of the cargo at Bradley was delayed due to an inoperable aircraft cargo loading system. The crew remained on the aircraft during the stopover. With a change in crew (captain and flight engineer), the aircraft departed Bradley on 14 October 2004 at 0403. The aircraft arrived at Halifax and loading of the aircraft was commenced. During this time, two crew members were observed sleeping in the upper deck passenger seats. The aircraft was refuelled with 72,062 kg uploaded, to provide a total of 89,400 kg of fuel on board. The ground engineer checked the aircraft fuelling panel and signed the fuel ticket. He then went to the main cargo deck to assist with loading. Once the loading had been completed, the ramp supervisor retrieved the cargo and flight documentation from the upper deck. While the loadmaster was completing the documents, the ramp supervisor went to the cockpit and noticed that the first officer was not in his seat. About 10 minutes later, the ramp supervisor left the aircraft with the completed documentation. The aircraft was taxied to the runway and during the takeoff the aft fuselage momentarily contacted the runway. Several seconds later, the fuselage contacted the runway again with greater force. Contact with the runway continued to about 825 ft beyond the end of the runway, where the aircraft became airborne. The lower aft fuselage then struck an earth bank supporting the instrument landing system antenna and the tail separated from the aircraft. The rest of the aircraft continued forward until it struck terrain. The aircraft was destroyed by the impact forces and subsequent fire. All seven of the crew members received fatal injuries.
Contributing factorsThe following factors were identified throughout the subsequent investigation: Flight data recorder comparison The flight data recorder information for the take-off at Halifax was compared with the takeoff at Bradley to identify any similarities. This comparison identified that the rotation speed and flap setting for both flights were about the same, however, at Bradley the aircraft reached VR 13 seconds before that recorded for the Halifax takeoff, indicating a higher rate of acceleration. Furthermore, the initial pitch rate for the Bradley takeoff was 1.2 degrees per second and the aircraft climbed away about 4 seconds later, with the pitch angle increasing to 6 degrees. For the Halifax takeoff, the initial pitch rate was 2.2 degrees per second, with the aircraft lifting off near 10 degrees. This eventually increased to 14.5 degrees. The take-off data for Halifax was nearly identical to that for the takeoff at Bradley, indicating that the Bradley TOW (239,783) kg was used to generate the performance data for Halifax. The calculated TOW for Halifax was 353,800 kg.
In order to calculate the take-off performance data, landing performance data, and weight and balance information for a flight, the crew were required to use the Boeing Laptop Tool (BLT), which was located on the upper deck of the aircraft. It was likely that the use of the wrong TOW came from the misuse or misunderstanding of how the BLT software functioned. When the BLT program was launched, the data for the previous flight would populate all of the fields, in this case, the data for Bradley. These fields would then need to be updated with the data for Halifax. If the user opened up the weight and balance page, and then returned to the take-off performance page, the TOW already in the system would automatically populate the planned weight on the take-off and performance page, which was 240,000 kg for Bradley. If the user was unaware of the software’s reversion feature or did not notice the change, and they selected the ‘calculate’ button, the resulting V speeds and thrust settings for the takeoff at Halifax would have been based on the data for Bradley. If these figures were written on the take-off data card with the correct TOW of 353,300 kg, it is likely that the error would have gone unnoticed.
It was likely that an independent check of the take-off data card was not performed by the crew as required by the standard operating procedures (SOPs). The crew did not conduct a gross error check in accordance with the SOPs. The crew were at their lowest level of performance due to fatigue, which may have increased the probability of error when calculating the take-off performance parameters, and degraded their ability to detect the error. Crew fatigue and the dark take-off environment contributed to a loss of situational awareness. The airline did not provide formal training on the use of the BLT, nor did they have a testing program. Airbus A340: August 2005
History of the flightOn 24 August 2005, an Airbus A340-300 aircraft, registered LN-RKF, was being prepared for a scheduled passenger service from Shanghai-Pudong International Airport, with 12 crew and 244 passengers onboard. About 30 minutes prior to the scheduled departure, the crew received the preliminary load information via the ACARS that indicated a ZFW of 179,110 kg and a TOW of 259,514 kg. As the captain was temporarily away from the cockpit, the pre-flight preparations had been delegated to the second officer. When entering the data into the ACARS take-off data calculation (TODC) computer, the ZFW was used instead of the TOW. Soon after, the final loadsheet was received; the TODC was not updated. When the captain arrived, the majority of the pre-flight preparations had been completed. The flight plan was completed by the first officer. The captain checked the loadsheet and flight plan, and then signed the plan. The second officer read-out the TODC speeds to the captain, who then entered them into the MCDU. The captain observed that the difference between the V1 and VR speeds was small; however, no further action was taken. The captain believed that the last line of defence was incorporated into the ACARS TODC, similar to that previously experienced when he had flown the Boeing 767. The captain and first officer verified the take-off data calculations prior to departing the gate and while taxiing, but the error was not detected. During the takeoff, liftoff was not achieved as expected. Additional control inputs were made and the aircraft’s fuselage contacted the runway. Take-off/go-around thrust was applied by the first officer at the same time the aircraft became airborne.
Contributing factorsThe following factors were identified throughout the subsequent investigation: The ZFW was inadvertently entered into the ACARS TODC instead of the TOW, resulting in low V speeds. The error went undetected by the crew.
The second officer did not have immediate access to the flight plan to confirm the aircraft’s TOW. The ACARS TODC computer requires input of the TOW, while the MCDU requires input of the ZFW. The captain was temporarily pre-occupied. All crew members were previously qualified on the Boeing 767 aircraft, where the TOW was similar to the ZFW of an A340. The take-off data was calculated by a crew member who was not responsible for checking the data or entering it into the MDCU. The data was entered into the TODC computer using a third MCDU, which was not visible to the other two crew members. The captain and first officer were also qualified on the Airbus A330 aircraft where the V speeds and thrust settings are lower than that of the A340. The V speeds were verbally provided to the pilot flying. The printed calculations were not shown. The ACARS TODC software would accept unrealistic low weights and mismatched V speeds without challenge. The duties of the second officer were not clearly defined by the airline. Embraer 190: July 2006
History of the flightOn 12 July 2006, an Embraer 190-100 aircraft, registered C-FHIU, was being operated on a scheduled flight from Toronto to Edmonton, Canada and return. On arrival at Edmonton, the aircraft was powered down to clear a fault message. As the aircraft servicing was to be completed with only battery power, the captain (pilot not flying) left the cockpit to supervise refuelling and servicing of the lavatory system. At the same time, the first officer (pilot flying) was completing the pre-flight walk around inspection. The first officer returned to the cockpit and calculated the preliminary take-off performance data using the captain’s laptop computer. The captain’s computer was used as the first officer’s laptop power cord was defective. When inputting the data, the first officer entered the weight of the fuel on board at the time (3,700 kg) instead of the planned fuel for departure (10,200 kg). The resulting TOW and V speeds were transcribed onto the flight plan. The captain returned to the flight deck and assumed his responsibilities as pilot not flying and entered the preliminary take-off performance data into the FMS. The crew received their clearance from ATC and completed the pre-flight fuel check, which involved comparing the fuel gauge indication with the flight plan. Shortly after, the crew were advised that water was overflowing from a coffee maker in the galley. The first officer communicated with the flight attendant to resolve the problem. At the same time, the captain was advised that the departure runway had changed. The captain recalculated the take-off performance data to reflect the runway change. The updated data was compared with the previous data. As the new data was similar to the previous data, the captain did not identify the incorrect fuel weight or TOW. The new thrust and V speeds were entered into the FMS. During taxi, the crew received the final load data. These values were compared to the flight plan and accepted as the values were within the prescribed company tolerances. During the takeoff, the crew noticed that the aircraft’s pitch response was different from normal and the aircraft felt out of trim and slow to respond. Soon after, the crew reviewed the performance data on the laptop computer and noted the discrepancy. Contributing factorsThe following factors were identified throughout the subsequent investigation: An incorrect aircraft weight was used to calculate the take-off performance data. The error was not detected by the crew, resulting in the aircraft taking off with lower than required thrust and V speeds.
The requirement to power down the aircraft and the laptop computer power cord defect increased the crew’s workload and interrupted their process for preparing the aircraft for departure. This resulted in the crew deviating from the airline’s SOPs. The pilot flying calculated the take-off performance data. The SOPs required the pilot not flying to calculate the data and the pilot flying to verify the data before being transcribed onto the flight plan. The SOPs required the crew to transcribe the data onto the flight plan; however, there was no designated location on the plan for the figures. This made it difficult for the crew to compare the calculated take-off performance figures with the planned figures.
History of the flightOn 10 December 2006, a Boeing 747-400 aircraft, registered F-HLOV, was being prepared for a scheduled passenger service from Paris-Orly airport, with 15 crew and 563 passengers onboard. On arrival at the aircraft, the crew found that the battery of one of the two BLT’s used to calculate the take-off performance parameters was flat; consequently, the second BLT (operating on battery power) was used. During the pre-flight preparations, the first officer noted a fault message relating to the hydraulic circuit. Discussions with the ground mechanic determined that the issue was being dealt with. When determining the take-off performance parameters for the flight, the captain provided the first officer with the ZFW from the weight and balance sheet, which he increased by 1.6 tonnes, and the TOW. The first officer then entered the ZFW into the FMS. The TOW was entered into the BLT and the take-off performance parameters calculated. The first officer handed the BLT to the captain to cross-check the calculations. The BLT then went into standby and the captain handed it back to the first officer who unintentionally turned it off, thus erasing the entered data. At the same time, the captain was dealing with the hydraulic failure issue with the mechanic in the cockpit. When the new data was being entered into the BLT, the captain inadvertently called out the ZFW instead of the TOW. A weight of 242,300 kg was entered into the BLT instead of 341,300 kg. The captain entered the resultant BLT data into the FMS, replacing the values automatically calculated by the FMS. The first officer then verified that the BLT and FMS values were identical. The captain entered the assumed take-off temperature into the FMS and queried the reduced thrust value with the first officer. The first officer justified these figures by the fact that the QNH was high and the temperature was low. The crew performed a rolling takeoff and did not detect that the aircraft’s acceleration was lower than normal. At the V1 speed, the crew noted that there was a reasonable amount of runway length still available and they began to doubt the V speeds. The captain (the pilot not flying) elected to delay the aircraft’s rotation. When the first officer began the rotation, he immediately noticed that aircraft appeared heavy. The aircraft’s pitch was increased slowly, but the stick-shaker activated. The first officer responded by reducing the aircraft’s nose-up attitude and applying full take-off power. Ground personnel noticed smoke during the aircraft’s rotation. After the takeoff, the crew suspected a problem with the calculated V speeds and increased the retraction speeds for control surfaces by 20 kts. Contributing factorsThe following factors were identified throughout the subsequent investigation: The ZFW was inadvertently read aloud and subsequently entered into the BLT instead of the TOW, resulting in V speeds that were too low.
The BLT was not connected to the aircraft’s power source and it went into standby mode. The captain was dealing with a hydraulic failure at the time the take-off performance calculations were being calculated. After the data had been entered into the FMS, there was no requirement for a comparison to be made with the TOW and the flight limitations. There was no requirement to compare the data entered into the BLT with the data entered into the FMS. Airbus A340: March 2007
History of the flightOn 28 March 2007, an Airbus A340 aircraft, registered F-GLZP, was being prepared for takeoff from Charles de Gaulle International Airport, France. The crew had initially planned to conduct a reduced thrust takeoff. However, due to a 5 kt tail wind, this was changed and the take-off performance parameters were re-calculated. When entering the V speeds, an error was made, resulting in the VR speed being 20 kts lower than required. During the takeoff, the pilot flying delayed the aircraft’s rotation.
Boeing 747: June 2007
History of the flightOn 2 June 2007, a Boeing 747-300 aircraft, registered HZ-AIT, was to be operated on a scheduled passenger service from Changi Airport, Singapore to Riyadh, Saudi Arabia. The first officer and flight engineer arrived at the aircraft and received a briefing from the handling agent’s dispatcher. The captain arrived shortly after and the briefing was repeated. During the brief, the dispatcher advised the crew that runway 20C had been shortened, which was not reflected in the company’s Notice to Airmen. The flight engineer had also listened to the ATIS, which stated that the runway in use was runway 20C and the take-off run available (TORA) was 2,500 m. The full length of the runway was 4,000 m. The crew then calculated the take-off performance data using the computer generated module table take-off and landing (MTTL) charts provided by the dispatcher. The MTTL charts, for certain flap setting, allowed the crew to determine a zero wind TOW limit corresponding to a particular outside air temperature value and direction of takeoff (runways 02C/02L/20C). The table spread over two pages, with the runway length information appearing only on the second page of the MTTL charts. The crew reported that the MTTL charts provided were different from what they normally received, which contained the outside air temperature versus the TOW limits data for one particular runway and runway length. As the first officer was not familiar with the new format of the MTTL charts, he consulted the captain. The captain identified the correct column on the chart corresponding to the reduced runway length; however, the first officer incorrectly read the take-off data from the column applicable for a full runway length take-off. The first officer did not notice the runway length on page 2 of the chart. The crew contacted ATC, requesting a clearance for flight level 330. At this stage, ATC informed the crew twice that they should expect runway 20C and that the TORA was 2,500 m. The crew received a clearance from ATC to line up on runway 20C and were again advised that the TORA was 2,500 m, before receiving a clearance for takeoff. During the takeoff, the crew noticed the red runway-end lights and the flight engineer also reported that he sensed that the aircraft was too low and was expecting to feel or hear the aircraft hit the lights. The crew reported that they did not feel or hear anything during the takeoff, however, the runway end marker board lights turned off shortly after the aircraft became airborne. A subsequent inspection determined that the marker boards were badly damaged. During the takeoff, a group of workers were doing runway re-surfacing work at the end of runway 20C. The workers reported that when the aircraft flew overheard, it was low enough that there reaction was to squat down. Figure 11: Damaged runway end marker board lights
Source: Air Accident Investigation Bureau of Singapore, 2008 Contributing factorsThe following factors were identified throughout the subsequent investigation: The first officer determined the aircraft TOW limit using the full runway length available column on the MTTL chart instead of the reduced runway length column. The captain did not cross-check the first officer’s calculations. There was no requirement by the airline for the crew to cross-check each other’s calculations. The crew were not familiar with the new format of the MTTL charts as they weren’t informed of the change. The first officer only referenced the first page of the MTTL chart, and consequently, did not notice the runway length figure for the particular column being referenced. McDonnell Douglas MD83: September 2007
History of the flightOn 9 September 2007, a McDonnell Douglas MD83 aircraft, registered OE-LRW, was being prepared for a charter passenger flight from Åre/Östersund Airport, Sweden to Antalya Airport, Turkey with six crew and 169 passengers onboard. For the flight, the crew were responsible for the loading instructions, preparing the load and trim sheet, and performance calculations. The crew had elected to use runway 30 with a tail wind as this runway allowed for a higher TOW than the runway in the opposite direction. In preparation for the flight, the crew obtained the maximum permitted TOW for runway 30 using gross weight charts (GWC). According to the load and trim sheet, the aircraft’s actual TOW was 70,169 kg, while the maximum permitted TOW for runway 30 was 70,651 kg (uncorrected). These charts also provided information relating to the V speeds and took into account the physical data of the aircraft, the height of the aerodrome above sea level, the actual aircraft TOW according to the load and time sheet, wind, temperature, air pressure, runway conditions, and the wing flap setting required for takeoff. When determining the maximum permitted TOW, the tail-wind and current atmospheric air pressure conditions were omitted. During the takeoff, the captain felt that the aircraft rotation was heavier than normal. A slow rotation was conducted to avoid a tailstrike and the aircraft became airborne at the end of the runway. After rotation, the aircraft had to be trimmed more to the rear than normal. A subsequent inspection determined that the aircraft had struck the approach lights. The captain later reported that he believed the take-off performance calculations were based on the wind information provided in the weather forecasts and could not remember the actual wind direction provided by ATC. The first officer could not remember why he had made the calculations based on zero wind. In addition, a number of baggage items in the forward cargo compartment were not included in the weight calculations. When loading of the aircraft was completed, the handling agent provided the captain with a verbal report. According to the agent, he advised that there were 29 bags in the forward cargo compartment, which were not included on the load and trim sheet. The captain believed that the agent stated that there was only a ‘few’ bags in the compartment. The captain told the handling agent that he would make the necessary changes to the load and trim sheet. The corrections were not made as the captain believed that the airline’s regulations stated that corrections were not required for values less than 500 kg. The manual only stated that if the weight changes were less than 500 kg, a new load and trim sheet was not required, however, the changes did need to be included on the existing sheet. The aircraft was 3,148 kg heavier than the maximum allowable weight for the prevailing conditions.
Contributing factorsThe following factors were identified during the subsequent investigation: The weather and wind conditions were not included in the calculations for determining the maximum allowable TOW. Loading instructions were communicated verbally between the crew and ground staff, resulting in a difference of understanding with respect to the additional baggage in the forward cargo compartment. An analysis of the takeoff determined that the aircraft rotation was initiated late and too low a rotation rate was used. Due to the seasonal requirements of charter flights, the pilot group was not homogeneous, with pilots from different backgrounds and differing periods of employment. This resulted in high demands on the management and safety guidance within the airline to ensure a high level of safety was maintained and to prevent an undesirable culture from developing.
History of the flightOn 28 October 2008, the crew of an Airbus A330-243 aircraft, registered G-OJMC, reported for duty at Sangster International Airport, Jamaica to operate a passenger service to London, UK. During pre-flight preparations, the crew (captain, first officer and a supernumerary pilot) were unable to locate the aircraft’s performance manual. The captain contacted the flight dispatch department via telephone and requested that the take-off performance data be calculated using the Airbus flight operations versatile environment (FOVE) computer system. The captain relayed the relevant information to the dispatcher to enter into the FOVE system. The resultant figures were then read back to the captain. The telephone was then handed over to the first officer and this process repeated. Both the captain and first officer reported receiving the same take-off performance figures. These figures were then entered into the FMGS. During the takeoff, the aircraft appeared to accelerate as expected. After passing 100 kts, the first officer called ‘V1’ and ‘VR’. The captain was surprised by the quick succession of these calls. The first officer called ‘rotate’ and the captain pulled back on the sidestick. When doing so, the aircraft did not appear to feel right and the captain immediately applied TO/GA thrust. The aircraft became airborne and climbed away. After completing the after take-off checklist, the crew checked the take-off performance figures against the data contained in the flight crew operating manual. This comparison identified significant differences between the two.
Contributing factorsWhile the exact source of the error could not be identified, the following factors were identified by the subsequent investigation: A TOW of 120,800 kg was used by the dispatcher instead of 210,183 kg to calculate the take-off performance parameters resulting in erroneous V speeds.
The function in the FOVE computer to calculate the green dot speed11 was disabled. If the green dot speed from the FOVE computer was provided to the crew, this figure could have been used to compare the green dot speed automatically generated by the FMGS as a gross error check. The procedure for calculating and verifying the FOVE calculations were not completely carried out. The airline’s procedures stipulated that the dispatcher was required to obtain the input data from one of the crew members and enter it into the FOVE computer. Both the input figures and resultant data are then read back to that crew member. The dispatcher was then required to hand over the FOVE computer to a second dispatcher, who would then go through the same process with a different crew member. If a second dispatcher was not available, the duty pilot was contacted, who had his own FOVE computer, and the second calculations were to be made. Boeing 767: December 2008
History of the flightOn 13 December 2008, a Boeing 767-39H aircraft, registered G-OOAN, was scheduled to fly from Manchester Airport, United Kingdom to Montego Bay, Jamaica. On board the aircraft were 11 crew and 254 passengers. Prior to receiving the loadsheet, the crew entered the required information into the computer take-off programme (CTOP) (laptop computer), with the exception of the aircraft TOW, which was required from the loadsheet. When later entering the required weight information, the ZFW was inadvertently entered instead of the TOW. The calculated V speeds and thrust setting were then entered into the FMC. The aircraft was pushed-back from the gate about 15 minutes late. While taxiing, it began to rain heavily and the temperature engine anti-ice was required to be on. The first officer re-calculated the V speeds using the CTOP and informed the captain that there was no change to the speeds. The crew’s attention was also focussed on the taxi, due to works in progress on some of the taxiways. The captain was paying particular attention to their taxi route as he was not familiar with the airport. During the takeoff, the captain elected to delay the V1 call by 10 to 15 kts due to a sluggish acceleration as he believed the aircraft may have been heavier than calculated. The first officer rotated the aircraft slowly. The tailskid message on the engine instrument and crew alerting system (EICAS) illuminated momentarily, indicating a tailstrike. In response, the captain applied full power. Soon after, the stick shaker activated briefly. The aircraft continued to climb away. Contributing factorsThe following factors were identified throughout the subsequent investigation: The ZFW was entered into the CTOP instead of the TOW, resulting in significantly lower V speeds than required for the aircraft’s actual weight.
The captain had flown a number of sectors in an empty Boeing 767 aircraft prior to the incident flight; consequently, the slow V speeds did not trigger an alert. The crew were distracted by the works in progress on the taxiways and were particularly attentive to the taxi routing. The delay in pushback led to a time pressure.
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